Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part II).

The electrodiagnostic (EDX) examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and complements imaging of the spine. In this second of a two-part review, the implications of electrodiagnostic findings for diagnosis and clinical management of persons with radiculopathy are reviewed. An EMG confirmed lumbosacral radiculopathy is associated with better clinical outcomes for persons undergoing aggressive conservative management. A positive EMG test portends a better clinical response to epidural corticosteroid injections. If a person undergoes spine surgery, a positive pre-operative EMG for radiculopathy is also associated with better outcomes.

Evaluation of persons with suspected lumbosacral and cervical radiculopathy: Electrodiagnostic assessment and implications for treatment and outcomes (Part I).

Persons with back, neck, and limb symptoms constitute a major referral population to specialists in electrodiagnostic (EDX) medicine. The evaluation of these patients involves consideration of both the common and less common disorders. The EDX examination with needle electromyography (EMG) is the most important means of testing for radiculopathy. This test has modest sensitivity but high specificity and well complements imaging of the spine. Needle EMG in combination with nerve conduction testing is valuable in excluding entrapment neuropathies and polyneuropathy-conditions that frequently mimic radicular symptoms. In this first of a two-part review, the optimal EDX evaluation of persons with suspected radiculopathy is presented. In part two, the implications of EDX findings for diagnosis and clinical management of persons with radiculopathy are reviewed.

Relevance of learning health systems to physiatrists and its synergy with implementation science: A commentary.

As health care attempts to bridge the gap between evidence and practice, the concept of the learning health system (LHS) is becoming increasingly relevant. LHS integrates evidence with health systems data, driving health care quality and outcomes through updates in policy, practice, and care delivery. In addition, LHS research is becoming critically important as there are several initiatives underway to increase research capacity, expertise, and implementation, including attempts to stimulate increasing numbers of LHS researchers. Physical Medicine & Rehabilitation (PM&R) physicians (physiatrists), nurses, therapists (physical therapists, occupational therapists, speech therapists, clinical psychologists), and scientists are affiliated with LHSs. As LHS research expands in health care systems, better awareness and understanding of LHSs and LHS research competencies are key for rehabilitation professionals including physiatrists. To address this need, the Agency of Healthcare Research and Quality (AHRQ) identified 33 core competencies, grouped into eight domains, for training LHS researchers. The domains are: (1) Systems Science; (2) Research Questions and Standards of Scientific Evidence; (3) Research Methods; (4) Informatics; (5) Ethics of Research and Implementation in Health Systems; (6) Improvement and Implementation Science; (7) Engagement, Leadership, and Research Management; and the recently added (8) Health and Healthcare Equity and Justice. The purpose of this commentary is to define LHS and its relevance to physiatrists, present the role of implementation science (IS) in LHSs and application of IS principles to design LHSs, illustrate current LHS research in rehabilitation, and discuss potential solutions to improve awareness and to stimulate interest in LHS research and IS among physiatrists in LHSs.

Personalized 3D exergames for in-home rehabilitation after stroke: a pilot study.

PURPOSE: To describe a novel 3-dimensional (3D) exergames system and the results of a clinical feasibility study of stroke survivors needing in-home rehabilitation. MATERIALS AND METHODS: The customisable Personalized In-home eXErgames for Rehabilitation (PIXER) system captures the user's image, generates a live model, and incorporates it into a virtual exergame. PIXER provides a recording system for home exercise programs (HEPs) by adapting virtual objects, customizes the exergame and creates a digital diary. Ten persons with stroke, performed HEPs with PIXER for 1 month, and without PIXER for 2 additional months. In-game performance data, measures of physical functioning (PF) including Stroke Impact Scale (SIS), Timed Up & Go (TUG) and Goal Attainment (GA) Scale obtained at baseline, 1- and 3 months were evaluated. RESULTS: Seventy percent of participants completed the 1-month timepoint, 50% completed all timepoints. In-game data: Number of repetitions completed; Anomalies reported; and Percentage of bubbles hit showed positive trends. Compared to baseline, all SIS physical functioning (PF) scores were higher at 1 month, TUG scores showed no overall improvement and GA scale scores were 77% at 3 months. CONCLUSION: It is feasible for community-dwelling patients to perform HEP after stroke using PIXER, a novel, exergames system, and potentially improve their function.IMPLICATIONS FOR REHABILITATIONHome Exercises performed using a novel, 3-dimensional, customizable Personalized In-home eXErgames for Rehabilitation (PIXER) system is feasible for community-dwelling patients after stroke.In-game performance data obtained in this clinical pilot study showed positive trends of improvement in several study participants.PIXER has potential to improve functional outcomes for community-dwelling adults with stroke.

A novel mixed reality system to manage phantom pain in-home: results of a pilot clinical trial.

Introduction: Mirror therapy for phantom limb pain (PLP) is a well-accepted treatment method that allows participants to use a mirror to visually perceive the missing limb. Mixed reality options are now becoming increasingly available, but an in-home virtual mirror therapy option has yet to be adequately investigated. Methods: We had previously developed a mixed reality system for Managing Phantom Pain (Mr. MAPP) that registers the intact limb and mirrors it onto the amputated limb with the system's visual field, allowing the user to engage with interactive games targeting different large lower limb movements. Feasibility and pilot outcomes of treating patients with lower extremity PLP by using Mr. MAPP at home for 1 month were evaluated in this study. Pain intensity and interference were assessed using the McGill Pain Questionnaire, Brief Pain Inventory, and a daily exercise diary. Function was assessed using the Patient Specific Functional Scale (PSFS). The clinical trial registry number for this study is NCT04529083. Results: This pilot study showed that it was feasible for patients with PLP to use Mr. MAPP at home. Among pilot clinical outcomes, statistically significant differences were noted in mean current pain intensity [1.75 (SD = 0.46) to 1.125 (SD = 0.35) out of 5, P = .011] and PSFS goal scores [4.28 (SD = 2.27) to 6.22 (SD = 2.58) out of 10, P = .006], with other outcome measures showing non-significant trends towards improvement. Discussion: This pilot study revealed that in-home use of Mr. MAPP has potential to provide pain relief and improve function in patients with lower extremity PLP and is feasible. Each scale used provided unique perspective on the functional impact of PLP. Further expanded studies and investigation, including a fully powered clinical trial, with these scales are warranted. Clinical Trial Registration: https://www.clinicaltrials.gov/ct2/show/NCT04529083, Identifier: NCT04529083.

Comparison of in-person and synchronous remote musculoskeletal exam using augmented reality and haptics: A pilot study.

INTRODUCTION: Utilization of telemedicine for health care delivery increased rapidly during the coronavirus disease 2019 (COVID-19) pandemic. However, physical examination during telehealth visits remains limited. A novel telerehabilitation system-The Augmented Reality-based Telerehabilitation System with Haptics (ARTESH)-shows promise for performing synchronous, remote musculoskeletal examination. OBJECTIVE: To assess the potential of ARTESH in remotely examining upper extremity passive range of motion (PROM) and maximum isometric strength (MIS). DESIGN: In this cross-sectional pilot study, we compared the in-person (reference standard) and remote evaluations (ARTESH) of participants' upper extremity PROM and MIS in 10 shoulder and arm movements. The evaluators were blinded to each other's results. SETTING: Participants underwent in-person evaluations at a Veterans Affairs hospital's outpatient Physical Medicine and Rehabilitation (PM&R) clinic, and underwent remote examination using ARTESH with the evaluator located at a research lab 30 miles away, connected via a high-speed network. PATIENTS: Fifteen participants with upper extremity pain and/or weakness. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Inter-rater agreement between in-person and remote evaluations on 10 PROM and MIS movements and presence/absence of pain with movement was calculated. RESULTS: The highest inter-rater agreements were noted in shoulder abduction and protraction PROM (kappa (κ) = 0.44, confidence interval (CI): -0.1 to 1.0), and in elbow flexion, shoulder abduction, and shoulder protraction MIS (κ = 0.63, CI: 0 to 1.0). CONCLUSIONS: This pilot study suggests that synchronous tele-physical examination using the ARTESH system with augmented reality and haptics has the potential to provide enhanced value to existing telemedicine platforms. With the additional technological and procedural improvements and with an adequately powered study, the accuracy of ARTESH-enabled remote tele-physical examinations can be better evaluated.

Methodological Issues Relevant to Blinding in Physical Medicine and Rehabilitation Research.

ABSTRACT: Blinding in research is important, and the field of physical medicine and rehabilitation poses special consideration owing to the patient populations and treatment methodologies used. Historically, blinding has been increasingly relevant to conducting good-quality research. The main reason to blind is to reduce bias. There are several strategies to blinding. At times, when blinding is not possible, alternatives to blinding include sham control and description of study and control groups. Illustrative examples of blinding used in physical medicine and rehabilitation research are described in this article, along with how to assess success and fidelity of blinding.

Quality of clinical practice guidelines on interventional management of low back pain: A systematic review.

OBJECTIVE: To appraise the quality of low back pain (LBP) clinical practice guidelines (CPG) that include interventional management recommendations and to associate their quality with characteristics including publication year and creating organization. TYPE: Systematic Review. LITERATURE SURVEY: LBP (subacute or chronic) CPGs in English (symptom based, governmental or professional society created, January 1990-May 2020) were found using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, ECRI, Guidelines International Network, NICE, and SIGN. METHODOLOGY: In this third order systematic review, search results were deduplicated, title and abstract screened by two independent reviewers, and full texts reviewed by four reviewers. Discrepancies were resolved by a third reviewer. Resulted CPGs were appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool by four appraisers each. Association of their quality with creating organization, geographical region, and year of creation was calculated. SYNTHESIS: Seven hundred fourteen screened documents resulted in 21 final CPGs. On appraisal, average overall CPG quality was 5.2 (range 2.5-6.75). Domain 5 (applicability) had the lowest average (44%) and domain 4 (clarity of presentation) had the highest average score (82%). For overall recommendation, 16 received "yes" or "yes with modifications," six received unanimous "yes" and two unanimous "no" votes. The interrater agreement of domain scoring was excellent (0.8-1.0; p < .001). There was no association found between quality of CPG and (1) year of publication (R2  = 0.0006), (2) whether the CPG was updated or new (p = .17), and (3) region of publication (p = .37). CONCLUSIONS: The majority of the 21 CPGs identified in this systematic review were of high quality, but overall quality and recommendation ratings were variable. The quality of appraised CPGs showed no association with their characteristics. Some domains such as "applicability" scored uniformly lower, revealing opportunity for improvement in future CPG development. LBP CPGs should be scrutinized before adopting their recommendations.

Clinical practice guidelines on interventional management of low back pain: A synthesis of recommendations.

OBJECTIVE: To summarize the recommendations on the interventional management of subacute and chronic nonradicular low back pain (LBP) from the 21 quality-appraised clinical practice guidelines (CPGs) identified in a previously published paper: "Quality of Clinical Practice Guidelines on Interventional Management of Low Back Pain: A Systematic Review." By disseminating this information, we aimed to facilitate the implementation of these recommendations into clinical practice. TYPE: Systematic Review LITERATURE SURVEY: Electronic bibliographic databases, guideline databases, and gray literature were searched from January 2016 to January 2020 to identify CPGs that met study criteria. METHODOLOGY: A total of 21 CPGs were quality appraised and interventional management recommendations were extracted and organized into several treatment categories including epidural steroid injections, radiofrequency procedures (RF), facet injections, sacroiliac injections, and prolotherapy. Within each treatment category, the recommendations were organized based on two factors: quality of CPG and strength of recommendation. SYNTHESIS: Overall, there was no consistency in recommendations for or against any interventional procedure, even when accounting for the quality of the CPG. In all of the CPGs reviewed, the most common strength of recommendation was weakly for. The second, third, and fourth most common strength of recommendations were inconclusive, weakly against, and strongly against, respectively, and the least common was strongly for. The treatment categories with the greatest number of recommendations were RF procedures (most common strength of recommendation was weakly for) and facet procedures. Among the high-quality CPGs, the most common strength of recommendation was inconclusive. CONCLUSIONS: Most of the interventional management recommendations for management of nonradicular LBP in the 21 CPGs appraised in this review were either weakly for, weakly against, or inconclusive, with several recommendations within each treatment category contradicting each other. Appraisal of Guidelines for Research & Evaluation Instrument quality appraisals of CPGs on interventional management of LBP were of unclear utility in guiding clinical implementation.

Learning Health Systems Research Competencies: A Survey of the Rehabilitation Research Community.

OBJECTIVE: The Learning Health Systems Rehabilitation Research Network (LeaRRn), an NIH-funded rehabilitation research resource center, aims to advance the research capacity of learning health systems (LHSs) within the rehabilitation community. A needs assessment survey was administered to inform development of educational resources. METHODS: The online survey included 55 items addressing interest in and knowledge of 33 LHS research core competencies in 7 domains and additional items on respondent characteristics. Recruitment targeting rehabilitation researchers and health system collaborators was conducted by LeaRRn, LeaRRn health system partners, rehabilitation professional organizations, and research university program directors using email, listservs, and social media announcements. RESULTS: Of the 650 people who initiated the survey, 410 respondents constituted the study sample. Respondents indicated interest in LHS research and responded to at least 1 competency item and/or demographic question. Two-thirds of the study sample had doctoral research degrees, and one-third reported research as their profession. The most common clinical disciplines were physical therapy (38%), communication sciences and disorders (22%), and occupational therapy (10%). Across all 55 competency items, 95% of respondents expressed "a lot" or "some" interest in learning more, but only 19% reported "a lot" of knowledge. Respondents reported "a lot" of interest in a range of topics, including selecting outcome measures that are meaningful to patients (78%) and implementing research evidence in health systems (75%). "None" or "some" knowledge was reported most often in Systems Science areas such as understanding the interrelationships between financing, organization, delivery, and rehabilitation outcomes (93%) and assessing the extent to which research activities will improve the equity of health systems (93%). CONCLUSION: Results from this large survey of the rehabilitation research community indicate strong interest in LHS research competencies and opportunities to advance skills and training. IMPACT: Competencies where respondents indicated high interest and limited knowledge can inform development of LHS educational content that is most needed.

Telehealth in PM&R: Past, present, and future in clinical practice and opportunities for translational research.

Telehealth refers to the use of telecommunication devices and other forms of technology to provide services outside of the traditional in-person health care delivery system. Growth in the use of telehealth creates new challenges and opportunities for implementation in clinical practice. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) assembled an expert group to develop a white paper to examine telehealth innovation in Physical Medicine and Rehabilitation (PM&R). The resultant white paper summarizes how telehealth is best used in the field of PM&R while highlighting current knowledge deficits and technological limitations. The report identifies new and transformative opportunities for PM&R to advance translational research related to telehealth and enhance patient care.

Needle electromyography predicts outcome after lumbar epidural steroid injection.

INTRODUCTION: Needle electromyography (NEE) would be more valuable if it could predict outcomes after lumbar epidural steroid injections (LESIs) in lumbosacral radiculopathy (LSR). METHODS: We investigated the predictive value of NEE for outcome after LESI compared with other known predictive variables in 89 subjects with clinical LSR. Seventy patients completed the study, which included diagnostic lower extremity NEE and LESI. Outcome measures included changes in pain, physical function, and psychosocial function [assessed using the Pain Disability Questionnaire (PDQ)]. RESULTS: NEE was an independent predictor of long-term pain improvement after LESI and was not predictive of PDQ functional improvement. A regression model, with NEE as one of several independent variables, showed strong outcome-predictive ability. CONCLUSIONS: NEE is an independent predictor of long-term pain relief after LESI for LSR. Abnormal NEE is predictive of better outcome than normal NEE. A regression equation including NEE and other independent predictors was predictive of pain and functional outcomes.

Phosphodiesterase 5 Inhibitor Use in Patients Undergoing Decompression Surgery for Lumbar Spinal Stenosis.

OBJECTIVE: Our objectives were to explore the association between phosphodiesterase 5 inhibitor use and lumbar decompression surgery by evaluating the prevalence of lumbar decompression surgery in a treatment group of patients with lumbar spinal stenosis compared with a control group. DESIGN: We performed database review and extracted data including lumbar decompression surgery prevalence, phosphodiesterase 5 inhibitor dosage, and fill dates. Treatment group was defined as those with phosphodiesterase 5 inhibitor fill dates of less than 30 days before surgery, and control group was defined as those with phosphodiesterase 5 inhibitor fill dates at any other time. Lumbar decompression surgery prevalence rates for both groups were calculated. RESULTS: Our study found 599 lumbar spinal stenosis patients who were prescribed phosphodiesterase 5 inhibitor. Three hundred thirty-eight underwent lumbar decompression surgery. Of these, 71 (21%) filled their prescription of less than 30 days before surgery, whereas 267 (79%) filled their prescription during a different period. The majority (94.6%) of surgical patients received decompression at two or more spinal levels. CONCLUSIONS: Prevalence of lumbar decompression surgery for lumbar spinal stenosis was significantly lower in patients in the treatment group on phosphodiesterase 5 inhibitor therapy compared with the control group. Among many potential explanations, the vasodilatory effect of phosphodiesterase 5 inhibitor may have contributed to a lower surgical rate. This is the first study to explore this novel association. Future prospective studies are necessary to better define the utility of phosphodiesterase 5 inhibitor in lumbar spinal stenosis.

Clinical feasibility and preliminary outcomes of a novel mixed reality system to manage phantom pain: a pilot study.

BACKGROUND: To assess the clinical feasibility of a virtual mirror therapy system in a pilot sample of patients with phantom pain. METHODS: Our Mixed reality system for Managing Phantom Pain (Mr. MAPP) mirrors the preserved limb to visualize the amputated limb virtually and perform exercises. Seven patients with limb loss and phantom pain agreed to participate and received the system for 1-month home use. Outcome measures were collected at baseline and 1 month. RESULTS: Four (of seven recruited) participants completed the study, which was temporarily suspended due to COVID-19 restrictions. At 1 month, in-game data showed a positive trend, but pain scores showed no clear trends. Functioning scores improved for 1 participant. CONCLUSIONS: Mr. MAPP is feasible and has the potential to improve pain and function in patients with phantom pain. TRIAL REGISTRATION: Clinical Trials Registration, NCT04529083.

Evidence-Based Medicine Training in United States-Based Physiatry Residency Programs.

ABSTRACT: Although the physiatric community increasingly embraces evidence-based medicine (EBM), the current state of EBM training for trainees in physiatry is unclear. The purposes of this article are to report the results of the Association of Academic Physiatrists' surveys of physiatry residency programs in the United States, to discuss the implications of their findings, and to better delineate the "baseline" upon which sound and clear recommendations for systematic EBM training can be made. The two Association of Academic Physiatrists surveys of US physiatry residency programs reveal that most survey respondents report that they include EBM training in their programs that covers the five recommended steps of EBM core competencies. However, although most respondents reported using traditional pedagogic methods of training such as journal club, very few reported that their EBM training used a structured and systematic approach. Future work is needed to support and facilitate physiatry residency programs interested in adopting structured EBM training curricula that include recommended EBM core competencies and the evaluation of their impact.

Lumbar Spinal Stenosis and Potential Management With Prostaglandin E1 Analogs.

ABSTRACT: Lumbar spinal stenosis is one of the most commonly diagnosed spinal disorders worldwide and remains a major cause for surgery in older adults. Lumbar spinal stenosis is clinically defined as a progressive degenerative disorder with low back pain and associated neurogenic intermittent claudication. Conservative and surgical management of lumbar spinal stenosis has been shown to be minimally effective on its symptoms. A treatment option that has not been investigated in the United States is the utilization of prostaglandin E1 analogs, which have been used primarily in Japan for the treatment of lumbar spinal stenosis since the 1980s. The vasodilatory and antiplatelet aggregation effects of prostaglandin E1 presumably improve symptoms of lumbar spinal stenosis by increasing blood flow to the spinal nerve roots. This brief report examines the potential vascular pathology of lumbar spinal stenosis, reviews evidence on the use of prostaglandin E1 analog limaprost in Japan for lumbar spinal stenosis, and briefly discusses misoprostol as a possible alternative in the United States. The studies summarized in this report suggest that prostaglandin E1 analogs may provide benefit as a conservative treatment option for patients with lumbar spinal stenosis. However, higher-quality studies conducted in the United States and comparison with other currently used conservative treatments are required before it can be recommended for routine clinical use.

Using Biometric Technology for Telehealth and Telerehabilitation.

This article discusses the use of physical and biometric sensors in telerehabilitation. It also discusses synchronous tele-physical assessment using haptics and augmented reality and asynchronous physical assessment using remote pose estimation. The article additionally focuses on computational models that have the potential to monitor and evaluate changes in kinematic and kinetic properties during telerehabilitation using biometric sensors such as electromyography and other wearable and noncontact sensors based on force and speed. And finally, the article discusses how virtual reality environments can be facilitated in telerehabilitation.

Lumbar Bracing for Chronic Low Back Pain: A Randomized Controlled Trial.

PURPOSE: We performed this study to evaluate the effect of back bracing to treat patients with chronic low back pain. METHODS: This was a prospective, unblinded, randomized controlled trial of 61 adults with uncomplicated chronic low back pain (>12 wks) and imaging findings of degenerative spondylosis, to assess the effectiveness of a semirigid back brace. All study participants received back school instruction. The treatment group also received a lumbar orthosis and was instructed to wear it as needed for symptom relief. At baseline, 6 wks, 12 wks, and 6 mos after intervention, we collected: Numerical Rating Scale to measure pain intensity, Pain Disability Questionnaire, Patient-Reported Outcome Measurement Information System, and EuroQol 5-Dimension (EQ-5D) to measure patient-reported function and quality of life. RESULTS: An interim analysis at the halfway point in enrollment (61 of 120 planned participants) revealed the Pain Disability Questionnaire, Patient-Reported Outcome Measurement Information System, and EQ-5D scores in the treatment group to be worse than in the control group, but no significant group differences in Numerical Rating Scale scores. Outcome differences between groups analyzed over time revealed (effect [P]): Pain Disability Questionnaire = 0.84 (0.04); Patient-Reported Outcome Measurement Information System = 0.78 (0.005); EQ-5D = 0.06 (0.01); and Numerical Rating Scale = 0.02 (0.6). We halted the study because continuation was unlikely to produce significant changes to the results. CONCLUSIONS: In patients with uncomplicated chronic low back pain, a back brace when combined with education and exercise instruction did not provide any pain relief compared with education and exercise instruction alone. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe the effect of lumbar back bracing on pain intensity in patients with chronic low back pain; (2) Discuss the effects of lumbar back bracing on pain-related disability, function, and quality of life in patients with chronic low back pain; and (3) Understand the role of lumbar back bracing in the treatment of patients with chronic low back pain. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The Physiatry Workforce in 2019 and Beyond, Part 1: Results From a Cross-sectional Survey.

OBJECTIVE: The aim of the study was to describe the current physiatrist workforce in the United States. DESIGN: An online, cross-sectional survey of board-certified physiatrists in 2019 (N = 616 completed, 30.1% response) collected information about demographic and practice characteristics, including age, sex, practice area, practice setting, hours worked, patient characteristics, staffing, and work responsibilities. Physiatrists were stratified by substantive practice patterns using a cluster analysis approach. Survey responses were arrayed across the practice patterns and differences noted. RESULTS: The practice patterns identified included musculoskeletal/pain medicine, general/neurological rehabilitation, academic practice, pediatric rehabilitation, orthopedic/complex conditions rehabilitation, and disability/occupational rehabilitation. Many differences were observed across these practice patterns. Notably, primary practice setting and the extent and ways in which other healthcare staff are used in physiatry practices differed across practice patterns. Physiatrists working in musculoskeletal/pain medicine and disability/occupational rehabilitation were least likely to work with nurse practitioners and physician assistants. Physiatrists working in academic practice, general/neurological rehabilitation, and pediatric rehabilitation were most likely to have primary practice settings in hospitals. CONCLUSIONS: Physiatry is an evolving medical specialty affected by many of the same trends as other medical specialties. The results of this survey can inform policy discussions and further research on the effects of these trends on physiatrists and physiatry practice in the future.

The Physiatry Workforce in 2019 and Beyond, Part 2: Modeling Results.

OBJECTIVE: The aim of this study was to assess the current and future adequacy of physiatrist supply in the United States. DESIGN: A 2019 online survey of board-certified physiatrists (n = 616 completed, 30.1% response) collected information about demographics, practice characteristics, hours worked, and retirement intentions. Microsimulation models projected future physiatrist supply and demand using data from the American Board of Physical Medicine and Rehabilitation, national and state population projections, American Community Survey, Behavioral Risk Factor Surveillance System, Medical Expenditure Panel Survey, and other sources. RESULTS: Approximately 37% of 8853 active physiatrists indicate that their workload exceeds capacity, 59% indicate that workload is at capacity, and 4% indicate under capacity. These findings suggest a national shortfall of 940 (10.6%) physiatrists in 2017, with substantial geographic variation in supply adequacy. Projected growth in physiatrist supply from 2017 to 2030 approximately equals demand growth (2250 vs. 2390), suggesting that without changes in care delivery, the shortfall of physiatrists will persist, with a 1080 (9.7%) physiatrist shortfall in 2030. CONCLUSION: Without an increase in physiatry residency positions, the current national shortfall of physiatrists is projected to persist. Although a projected increase in physiatrists' use of advanced practice providers may help preserve access to comprehensive physiatry care, it is not expected to eliminate the shortfall.